Understanding Insurance Coverage
Once your child is referred to the Occunpational Therapy and Physical Therapy Depatement at Cincinanti Children's Hospital Medical Center, it is important to understand your insurance coverage for treatment. Although every effort is made to contact your insurance carrier to determine eligibility, benefit information and authorization for services, it is your responsibility to understand your insurance coverage and obtain authorization for services. The department is staffed with two full-time financial service representatives to assist you with the insurance process.
Where and How Do I Begin?
First, contact your insurance provider to discuss your therapy coverage. The telephone number to your provider is usually listed on the back of your insurance identification card.
Secondly, review the article, "The Wise Consumer". You can download a copy of "The Wise Consumer" (120k) in portable document format (.pdf).
Reproduced from The Wise Consumer: Understanding Insurance Coverage, PT Magazine, 1999, vol 7 no 10 with the permission of the American Physical Therapy Association. This material is copyrighted, and any further distribution is prohibited.
You must have Adobe Acrobat" Reader installed on your computer to read this file. You can download Adobe Acrobat" Reader at Adobe's Web site by selecting the version appropriate for your type of computer.
Request Authorization for Services
- Contact your insurance company to ask if prior authorization or precertification is needed for occupational therapy or physical therapy services (whichever has been indicated). If this is required, please ask the insurance company what steps are needed to obtain authorization for therapy services. The parent/legal guardian is responsible for ensuring all insurance referrals are in place from the primary care physician or specialist.
- Please note, insurance referrals and therapy prescriptions are not the same. If you have secondary health insurance, you should also check with that insurance company for therapy coverage and authorization.
- Call us with questions. As a courtesy, our financial service representatives are available to answer questions, which may assist you in obtaining insurance authorization for occupational therapy or physical therapy treatment. Obtaining authorization for treatment can be a particularly lengthy process. You are encouraged to contact your insurance company as soon as possible following the evaluation to determine if treatment visits will be approved.
- Although your child's therapy can be scheduled prior to obtaining insurance authorization, without authorization, you will be responsible for payment. Unfortunately some insurance plans do not cover therapy services for particular diagnoses. Please check your policy.
- Follow up with your insurance provider to verify that payment will be approved. Insurance companies reserve the right to deny payment for services after they have authorized visits if they do not deem the services to be medically necessary. Payment is based on medical necessity according to your plan's policy limitations. A decision to pay for services will be made by the insurance company upon receipt of the claim and will be based upon the insured 's eligibility on the date of service.
What Do I Do If Coverage is Denied?
If therapy coverage is denied, you have the following options:
- Make an appeal to your insurance carrier for reconsideration. You must contact your insurance "Member Services" department to obtain an explanation of the appeals process. Please read the enclosed article,"The Wise Consumer," for more information.
- Choose to pursue the necessary services and "self-pay" for these services. Contact Patient Financial Services at 513-636-4427 to arrange a self-pay account and a payment plan.
- Talk with the evaluating therapist to explore if there are any less expensive options. (i.e., therapy on a less frequent basis with a home exercise/activity program, community-based services, etc.)
How Do I Explore Financial Assistance?
Contact our financial counselors at 513-636-4717 to discuss alternate financial services. These counselors are knowledgeable about a full range of financial and customer service benefits. They may assist you in applying for other financial aid programs, such as:
- Children's Health Insurance Program (CHIP)
- The Bureau for Children with Medical Handicaps (BCMH)
- Contact Family Resource Services (ARC Hamilton County) at 513-821-2113, ext. 109. This program offers assistance towards therapy services.
For further help or for answers to your questions regarding
insurance coverage, please contact our financial service
representatives at:
- 513-636-0198 – if your child is a new patient
- 513-636-8528 – if your child is a current patient
